Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?
A. A client who has peritonitis reports generalized abdominal pain.
A client who has peritonitis reports generalized abdominal pain that corresponds to the site of inflammation and infection in the peritoneum.
B. A client who has angina reports substernal chest pain.
A client who has angina reports substernal chest pain that reflects the ischemia and hypoxia of themyocardium.
C. A client who has pancreatitis reports pain in the left shoulder.
Referred pain is pain that is felt in a location different from its source due to shared nerve pathways or central nervous system processing. A client who has pancreatitis may experience pain in the left shoulder due to irritation of the diaphragm by pancreatic enzymes or inflammation. This pain is referred from the abdominal cavity to the shoulder through the phrenic nerve.
D. A client who is postoperative reports incisional pain.
A client who is postoperative reports incisional pain that is caused by tissue damage and inflammation at the surgical site.
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN adult medical surgical 2019 with NGN - Proctored Exam 3. Take the full exam now
Full Explanation
Referred pain is pain that is felt in a location different from its source due to shared nerve pathways or central nervous system processing. A client who has pancreatitis may experience pain in the left shoulder due to irritation of the diaphragm by pancreatic enzymes or inflammation. This pain is referred from the abdominal cavity to the shoulder through the phrenic nerve.
A client who has peritonitis reports generalized abdominal pain that corresponds to the site of inflammation and infection in the peritoneum. A client who has angina reports substernal chest pain that reflects the ischemia and hypoxia of the myocardium. A client who is postoperative reports incisional pain that is caused by tissue damage and inflammation at the surgical site.
Similar Questions
A nurse is assessing a client who has acute kidney failure. Which of the following findings should the nurse report to the provider?
A. Creatinine 0.8 mi/dl.
B. Weight gain 1.1 kg (2.4 lb) in 24 hr
Weight gain in a short period of time indicates fluid retention, which can worsen the client's condition and lead to complications such as pulmonary edema and hypertension. The nurse should report this finding to the provider and monitor the client's fluid balance and electrolytes.
C. Peripheral pulses 2+ bilaterally
D. Urine specific gravity 1.045
Full Explanation
Weight gain in a short period of time indicates fluid retention, which can worsen the client's condition and lead to complications such as pulmonary edema and hypertension. The nurse should report this finding to the provider and monitor the client's fluid balance and electrolytes.
A nurse is administering packed RBCs to a client. The client reports chills, lower back pain, and nausea 10 min after the infusion begins. Which of the following actions should the nurse take first?
A. Administer oxygen to the client.
B. Collect a urine sample.
C. Check the client's vital signs.
D. Stop the infusion.
The client is experiencing signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency. The nurse should stop the infusion immediately and disconnect the blood tubing from the IV catheter to prevent further exposure to the incompatible blood.
Full Explanation
The client is experiencing signs of an acute hemolytic transfusion reaction, which is a life-threatening emergency. The nurse should stop the infusion immediately and disconnect the blood tubing from the IV catheter to prevent further exposure to the incompatible blood.
A nurse is caring for a client who was admitted with nausea, vomiting, and a possible bowel obstruction. An NG tube is placed and set to low intermittent suction. Which of the following findings should the nurse report to the provider?
A. The amount of drainage is gradually decreasing.
B. The client's abdomen becomes distended and firm.
Abdominal distension and firmness indicate increased intra-abdominal pressure, which can compromise blood flow to the bowel and cause ischemia, necrosis, or perforation. The nurse should report this finding to the provider and assess for signs of shock or peritonitis.
C. The client reports being extremely thirsty with a sore throat.
D. The drainage is bright green in color with brown fecal material.
Full Explanation
Abdominal distension and firmness indicate increased intra-abdominal pressure, which can compromise blood flow to the bowel and cause ischemia, necrosis, or perforation.
The nurse should report this finding to the provider and assess for signs of shock or peritonitis.